Royal National Orthopaedic Hospital NHS Trust
New Consultant in young adult and adolescent hip Business Case
For Approval
· The post is required in order to maintain RNOHT as a centre of clinical excellence through the continuing provision and development of young adult and adolescent hip treatment;
· Strong underlying patient demand is identified which will ensure that the post is broadly cost neutral in year one and by year 2 provides an increase in turnover to the Trust of £0.75m and contribution of £0.13m;
· The proposal is consistent with the activity, income, cost and financial contribution assumptions in the overall business plan and financial plan agreed by the Trust Board.
1. Rational, Introduction and Strategic Context
1.1. The RNOHT is the one of only two providers in the London health economy that offers specialist surgical treatment of Hip Impingement and Hip Dysplasia. At present the demands on this service are being met by only one consultant. A further consultant is required to in order to:
· Maintain the clinical excellence of the service
· Enable the expansion and clinical development of the service
· Meet increasing patient demand
· Ensure that patients can be treated within 18 weeks.
1.2. The aim of the surgery is to reduce pain from the hip and reduce the chance of the development of arthritis in the joint. The benefits of the treatment on young adults and adolescents is significant as appropriate intervention before arthritis develops may stop this condition developing later in life or at the very least delay the onset. This type of surgery is successful in allowing patients to return to a high level of activity.
1.3. Strategically the post is required in order to maintain the RNOHT as a centre of clinical excellence in providing and developing new and emerging specialist procedures. The post generates significant revenue fort the RNOHT and provide an underpinning of one of the Trust’s key services that elevates the RNOHT to the position as a national tertiary orthopaedic hospital.
2. Current Service Provision
2.1. The current service provision is inadequate. Between July and December of this year a minimum of 50 patients will have their procedure undertaken by Mr Nejad in the independent sector to maintain activity targets.
2.2. One consultant undertakes one all day clinic and three theatre session, supported by a registrar a CNS and a fellow. Additionally, clinical development of the service through the provision of keyhole techniques cannot be met due to capacity constraints.
2.3. An additional consultant is required to clinically develop the service and deliver the service provision required to meet demand.
3. Demand
3.1. The volume of referrals for Mr Hashemi-Nejad the sole consultant that undertakes this service has increase from 416 in 2007 to an expected 624 in 2009. This represents a 50% increase over 2 years driven by the demand for the adolescent and young adult hip service. The number of patients being listed for procedures has also risen by 22% over the two year period.
3.2. There are 3 more patients being added to the waiting list than Mr Hashemi-Nejad is able to treat on average each week in 2009.
3.3. In order to sustain the current position capacity needs to increase by a minimum of 150 procedures per annum. There is also the backlog of 54 patients that will need treated.
3.4. Demand for the Mr Hashemi-Nejad’s service is increasing year on year which can only be met by capacity provided by an additional consultant with an interest in young adult and adolescent hip. Activity levels for the current service is set out in the table below:
2007 / 2008 / 2009*New Referrals / 416 / 572 / 624
1st OPA / 572 / 624 / 572
FU OPA / 2496 / 2548 / 2548
Addition to Waiting List / 468 / 520 / 572
Procedures Undertaken / 468 / 416 / 416
* projected based on data January –May 09
4. Proposed Service
4.1. Additional Workload
4.1.1. In order to meet the underlying growth in demand the recruitment of a 1.0 WTE consultant is required.
4.1.2. It is proposed that the consultant works alongside and trains with Mr Hashemi-Nejad in Clinic and Theatre on Monday and Friday respectively and have their own list on Tuesday AM and PM.
4.1.3. The post is also provisionally scheduled to undertake a clinic on Monday and Theatre sessions on Tuesday and Friday afternoon.
4.1.4. The consultant is to undertake a minimum of 150 procedures per annum in the first year and to see 286 new and up to 1200 follow-up outpatient appointments.
4.2. Proposed Job Plan
4.2.1. The post will be 10 PA’s of which there will be 3 theatre and 2 clinic sessions undertaken each week. Due to capacity the sessions have not been identified, although the job plan will be completed prior to recruitment.
4.3. Resources & Investment
4.3.1. Two additional clinic rooms and three theatre sessions will be required. The additional staffing to support the consultant appointment is detailed below. This will also be reflected in new theatre business case being presented to the 30 September 2009 Trust Board meeting. Furthermore, all additional imaging requirements are outlined in the Imaging business case being reviewed at the same meeting.
Type / Band & WTE / Costs (£)SDU / Consultant / 10 PA's / £105,000
SpR / £76,000
SHO / £65,000
Secretary / B4 1.0 / £27,623
Therapies / OT / B7 0.5 / £17,205
Physiotherapist / B7 1.0 / £34,410
Theatres* / 2 x Scrub Nurses / B5 0.64 / £20,568
1x Scrub Nurse / B3 0.32 / £7,116
1xODP / B5 0.32 / £10,284
2xB5 Recovery / B5 0.4 / £25,710
Anaesthetist / 3 PA's / £31,500
Orthotics / Consumables / £20,000
Medical Records / Clerk / B2 0.2 / £4,178
Centralised Booking / Scheduler / B4 0.27 / £5,880
Theatre equipment / £5,000
Diagnostics / Staffing costs covered within Imaging Business Case
Orthotics / Consumables / £20,000
Ward Nursing / Nurse / B5 1.0 / £38,100
Paediatric Nurse / B5 0.5 / £19,050
Outpatients / Scheduler / B4 0.5 / £13,500
Total Staff Costs / £546,124
*element of theatres business case attributable to this consultant
5. Financial Case
5.1. The new post will enable the volume of Mr Hashemi-Nejad’s unique workload to be increased by 37.5% in year 1 and it is anticipated that this will rise in year 2 to 50%. Including Outpatient episodes this will generate additional revenue to the Trust of £595,054 in Year 1 and £705.936 in Year 2 before costs. Due to the transition period the costs will slightly exceed revenue in year one but by year 2 the extra activity generated will contribute £129,350 to the Trust.
5.2. The additional theatre capacity required is not detailed in the costs as they are covered in the theatre expansion business case.
5.3. Summary Income and Expenditure:
Year 1 / Year 2Total Revenue / £595,054 / £750,526
Total Staffing Costs / £546,124 / £546,124
Total estimated variable costs – pathology, drugs, consumables, etc / £59,505 / £75,052
Surplus/(Deficit) / -10,575 / £129,350
6. Case for Change
6.1. The post is required in order to maintain RNOHT as a centre of clinical excellence through the continuing provision and development of key orthopaedic services. Strong underlying patient demand has been clearly identified which will ensure that the post is self-funding. The proposal provides an improved underpinning of one of the Trust’s key developing services.
7. Service Benefits and Risks
7.1. Benefits:
· Maintain the department as a centre of clinical excellence;
· Develop new techniques and maintain the RNOHT as being at the forefront of orthopaedic surgery;
· Continuing provision of high-volume specialist care to meet increasing patient demand;
· Ensure swift patient access and delivery of the 18 week target;
· Maximise efficiently through prospective cover to maintain services when one consultant is unavailable;
· Development of education, research and audit to improve patient care;
· Overcome reliance on one consultant for a key Trust service;
· Post is self-funding.
7.2. Risks of not undertaking change:
· The Trust would not be able to provide the services appropriate to patient need and demand;
· The Trust will not have access to specialist consultant staff to maintain and expand the service to meet patient demand;
· A unique service at RNOH would be overwhelmed;
· The service would not develop.
· Patients would breach the 26 week access target;
· Patients would not be treated within 18 weeks;
· Total dependence on one individual consultant to maintain a growing service;
· No financial gain for the organisation and a loss of revenue.
8. Recommendation
8.1. The Trust supports the business case to recruit an additional 1.0 WTE Consultant with a key interest in adolescent and young adult hip and the supporting infrastructure for this post outlined in this case.
Lead Director: Mrs Puckett
Clinical Leader/Corporate Dept: Mr Hashemi-Nejad
Clinical Director: Dr Sinisi
General Manager: Mr Waugh
Funding Year: 09/10
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